Author: Temesgen Beyene, Ethiopia

Assistant Professor of Emergency Medicine and Critical Care at Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia. Harvard Medical School Global Clinical Research Scholars Training Program graduate. Humanitarian Innovation Imitative (HI2) international fellow at Watson Institute for International and Public Affairs and alumni of Brown International Advanced Research Institute (BIARI). I am interested in clinical research, public health aspects of emergency medicine and disaster preparedness and planning. I am currently involved in educating junior doctors, creating media-based education focusing on public health emergencies. I also have a special interest in Emergency Medicine system development in resource-limited settings.

Organophosphate poisoning

Organophosphate poisoning
~ Temesgen Beyene, Ethiopia ~ Leave a comment

Introduction

  • Organophosphate compounds can be commonly found in insecticides and are associated with systemic illness.
  • Mortality is higher in developing countries where organophosphate pesticides are more commonly available.
  • Organophosphorus poisoning can result from occupational, accidental, or intentional exposure.
  • Its use as a suicidal agent is frequent.
  • The primary cause of death in acute organophosphate poisoning is bradyasystolic arrest from respiratory failure.

Pathophysiology

Organophosphate compounds bind irreversibly to acetylcholinesterase inactivating the enzyme through the process of phosphorylation and acetylcholine at nerve synapses and neuromuscular junctions. Thus, it results in overstimulation of acetylcholine receptors.

Clinical presentation

Here are a few mnemonics for the Muscarinic Effects of Cholinesterase Inhibition: SLUDGE, DUMBELS, and Killer B’s (Figure 1 & 2).

SLUDGE - DUMBELS
Killer B's
  • Out of four distinct syndromes that can occur from organophosphate poisoning, the first two are clinically important in emergency setting 1. Acute poisoning, 2.intermediate syndrome, 3.chronic toxicity, and 4.organophosphate induced delayed neuropathy. Of these syndromes, the intermediate syndrome is the most feared one as it presents with paralysis of the neck’s flexor muscles, muscles innervated by the cranial nerves, proximal limb muscles, and respiratory muscles. It occurs up to 40% of poisonings within 1 to 5 days of initial symptoms.
  • Acute organophosphate poisoning can present with differing severities. Mild poisonings generally present with symptoms like lightheadedness, nausea, headache, dyspnea, lacrimation, rhinorrhea, salivation, and diaphoresis while moderate poisonings cause autonomic instability, confusion, vomiting, muscle spasms, bronchorrhea and bronchospasm. Coma, seizures, flaccid paralysis, urinary and fecal incontinence, and respiratory arrest may occur in the course of severe poisonings.
  • Diagnosis is based on history (people may bring bottles/substance itself) in the presence of a suggestive toxidrome. Cholinesterase assays and reference laboratory testing for specific compounds may confirm the diagnosis but take time and have limitations. Treatment should be started without delay based on the clinical findings.
  • Miosis (papillary constriction) and muscle fasciculation are the most reliable signs of organophosphate toxicity and help in diagnosis.

Treatment

  • The first step of the treatment is decontamination. Healthcare workers must wear protective equipment to avoid secondary poisoning. The patient should be decontaminated with ample water and soap preferably before arriving in a hospital or once stable. Water should be disposed of as hazardous waste.
  • In addition to decontamination, treatment consists of airway control, intensive respiratory support, general supportive measures, prevention of absorption, and the administration of antidotes.
  • The patient should be monitored continuously and provided 100% oxygen. Gastric lavage and activated charcoal are not recommended.
  • A non-depolarizing agent should be used when the neuromuscular blockade is needed during intubation since succinylcholine is metabolized by plasma butyrylcholinesterase, and therefore, may prolong paralysis.
  • The specific agents are atropine and Atropine can be given repeatedly every 5 minutes until tracheobronchial secretions attenuate (1-3 mg IV in adults or 0.01-0.04 mg/kg IV in children – never <0.1 mg per dose). Then, a continuous infusion should be started to maintain the anticholinergic state (0.4-4 mg/h in adults).
  • Pralidoxime is the single most important treatment for the nicotinic effect of organophosphate poisoning and is life-saving for intermediate syndrome if used within 48 hours (First dose: 1-2 g in adults or 20-40 mg/kg – up to 1 g – in children, mixed with NS and infused over 5-10 min, continuous infusion: 500 mg/h in adults or 5-10 mg/kg/h in children)
  • Seizures can be treated with benzodiazepines.

Disposition and follow-up

  • Minimal exposures may require only decontamination and 6 to 8 hours of observation in the ED to detect delayed effects.
  • Admission to the intensive care unit is necessary for significant poisonings.
  • Most patients respond to pralidoxime therapy with an increase in acetylcholinesterase levels within 48 hours.
  • The endpoint of therapy is the absence of signs and symptoms after withholding pralidoxime therapy.
  • Death from organophosphate poisoning usually occurs in 24 hours in untreated patients, usually from respiratory failure secondary to paralysis of respiratory muscles, neurologic depression, or bronchorrhea.

References and Further Reading

  1. Burillo-Putze, G. & Xarau S. N. “Pesticides. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, editors. Tintinalli’s emergency medicine: a comprehensive study guide 8th ed.” (2016): 1318-25.
  2. Katz K. D. & Brooks D. E. “Organophosphate Toxicity Treatment & Management” Medscape, Dec 31, 2020, https://emedicine.medscape.com/article/167726-treatment. Accessed Feb 05, 2021.
Cite this article as: Temesgen Beyene, Ethiopia, "Organophosphate poisoning," in International Emergency Medicine Education Project, March 29, 2021, https://iem-student.org/2021/03/29/organophosphate-poisoning/, date accessed: June 7, 2023

Emergency Department Crowding: A conceptual model

~ Temesgen Beyene, Ethiopia ~ Leave a comment

Overcrowding is a serious problem in healthcare systems all around the world. In particular, Emergency Departments, which, by definition, deal with acute and unscheduled patients, are more susceptible to overcrowding. Even the parts of the world with developed hospital systems suffer from ED overcrowding, the burden is heavier in the developing world. Emergency department crowding is a significant barrier that prevents patients from receiving adequate and timely care.

Researchers of this field and policymakers had recognized the importance of the problem for ages, but COVID-19 pandemic highlighted it once again. Asplin et al’s conceptual model, published in Annals of Emergency Medicine in August 2003, continues to be relevant today and helps all stakeholders of emergency care -researchers, policymakers and administrators alike- to come up with sounding solutions. According to this conceptual model (See figure below) causes of ED overcrowding is divided into 3 independent components, namely, input causes, throughput causes and output causes.

At different times, multiple components occur to some extent in all acute care centres. This conceptual model provides an overview of overcrowding causes so that administrators may review what’s failing and develop more efficient emergency department operations and policies. Subsequently, it will help to reduce ED crowding. Also, learning how ED, as a workplace, works on an organizational level has the potential to increase medical graduates’ interest in research and policymaking, thus, feedback on system design from diverse stakeholders.

The input-throughput-output conceptual model of ED crowding adapted from Asplin et al. August 2003

Reference

  • Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA Jr. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42(2):173‐180. doi:10.1067/mem.2003.302
Cite this article as: Temesgen Beyene, Ethiopia, "Emergency Department Crowding: A conceptual model," in International Emergency Medicine Education Project, June 19, 2020, https://iem-student.org/2020/06/19/emergency-department-crowding-a-conceptual-model/, date accessed: June 7, 2023

Pursuing clinical research as a medical student

Pursuing clinical research as a medical student
~ Temesgen Beyene, Ethiopia ~ Leave a comment

It all started as an undergraduate medical student.

I am an Assistant Professor of Emergency Medicine and Critical Care at Addis Ababa University, College of Health Sciences. As an Emergency Medicine physician, I am committed not only to develop my clinical skills in the Emergency Department but also to improving my skills in clinical research, which all started as a final year medical student during my undergraduate studies.

temesgen beyene

Emergency Medicine (EM) is a completely new specialty in Ethiopia by the time when I have started to pursue my specialty training, with not much research base exists to support our practice. Clinical research done elsewhere is rarely relevant here and many of the research questions asked elsewhere do not apply in our setting. As the practice of EM develops in Ethiopia, research to support that practice must develop also. I wanted to become an expert in the field of clinical research, so I can lead that development.

While I was having my three poster presentations at the International Conference on Emergency Medicine (ICEM 2016) in Cape Town South Africa and also participating in a two-day pre-conference workshop in Research Methodology, I heard news of my acceptance for a one year Harvard Medical School Global Clinical Scholars Research Training Program 2016/17.

temesgen beyene

This was after my own web-based search and application for clinical research training in addition to my residency training.

Global Clinical Scholars Research Training Program (GCSRTP) offered by Harvard University Medical School Office of Global Education is highly competitive clinical research training for clinical research scientists from all over the country. I am one of 113 advanced trainees from around the world selected for their ability and interest in pursuing clinical or epidemiological research. Students are drawn from hospitals, clinics, and academic communities globally and bring the unique perspective of their home country and institution to address research issues in a clinical or population-based setting.

temesgen beyene

This is a year-long intensive program is designed for clinicians and clinician-scientists aimed to achieve three goals: 

  1. To build skills in clinical research, 
  2. To provide knowledge to address issues critical for success in contemporary clinical research, and 
  3. To develop a global network. 

The GCSRTP consists of three on-site workshops (two in London, UK, and one in Boston) as well as 85 online lectures, 5 team assignments, 20 quizzes covering lecture content, a midterm and a final exam, as well as 2 or 3 interactive webinars per month in biostatistics, epidemiology, biostatistical computing, ethics and regulatory approaches, leadership, applied regression, longitudinal analysis and correlated outcomes, survey design, causal diagrams, and advanced quantitative methods. Additionally, I have selected an elective and a concentration and completed my own course work related to those tracks. The program requires an original research proposal as a Capstone Project. Graduation from the program relies on successful completion of this project. And thus, I had successfully completed my capstone project titled Diuretics Options in Acute Coronary Syndrome as a requirement for my successful graduation.

Through the Harvard Medical School Tuition Reduction Program, I was able to negotiate a 50% reduction in the usual tuition of $11,900 for the program. Additional expenses for travel and accommodation and supplies were my responsibility.

How all of the above came into fruition as a start base from my undergraduate study in Medicine?

There was a medical student mentorship research program of the Medical Education Partnership Initiative as a part of the NIH funded grant in 2013. For the same, I have assessed an undergraduate medical student’s clerkship rotation in Emergency Medicine as an Ethiopian experience. This paper, which was also published in the African Journal of Emergency Medicine, was a gateway for all of my clinical research experiences to date. There is a blog post about my clinical research experience in the same journal as well as I was a speaker on the most recent African Conference on Emergency Medicine in Kigali Rwanda, 2018.

My subsequent future as a clinical researcher:

I completed my residency in January 2018. With the skills developed in the GCSRT and my clinical qualification, I was well-positioned to apply for further clinical research fellowship at Addis Ababa University and got accepted for a Junior Faculty Research Fellowship under an NIH funded grant of Medical Education Partnership Initiative 2019-2020. I hope to begin developing research projects, possibly multi-site within Ethiopia that will address the many questions that are relevant to Emergency Medicine as it is practiced in our low-resource setting.

Cite this article as: Temesgen Beyene, Ethiopia, "Pursuing clinical research as a medical student," in International Emergency Medicine Education Project, February 28, 2020, https://iem-student.org/2020/02/28/pursuing-clinical-research-as-a-medical-student/, date accessed: June 7, 2023

A mnemonic for the care of critical ED patients

A mnemonic for the care of critical ED patients
~ Temesgen Beyene, Ethiopia ~ Leave a comment

Emergency departments and critical care units are very busy areas with a high turnover of patients, as well as the urgency of care provided with even smaller details matter in routine patient management. There should be strong efforts to improve the quality of patient care and to reduce medical errors, which are dangerous in such complex and busy areas. Thus, to support safe, effective care and closed-loop communication, patient medical records should be up to date so that timely care should be provided in emergency departments and ICU. Different protocols, standard operating procedures, checklist and physician rounds are all part of the attempt to improve clinical care. Very strict care is mandatory irrespective of the cause in critically ill and emergency patients. For the same, a shortened mnemonics for remembering elements of routine care is very important both in the emergency department and ICU. This is very important in daily clinical rounds.

In 2005, Jean Vincent came up with FAST HUGS, an abbreviated mnemonic for remembering important issues to look for in critical patients. It was basically a CME exercise from its origins and developed into an interesting article (1).

Subsequently, after four years, it became a valuable tool, and Vincent and Hatton upgraded the mnemonic to FAST HUGS BID in 2009 by including additional components of spontaneous breathing trial, bowel care, indwelling catheter removal and de-escalation of antibiotics (2).

  • Feeding/fluids
  • Analgesia
  • Sedation
  • Thromboprophylaxis
  • Head up position
  • Ulcer prophylaxis
  • Glycemic control
  • Spontaneous breathing trial
  • Bowel care
  • Indwelling catheter removal
  • De-escalation of antibiotics

Chris Nickson on Life In The Fast Lane Critical Care Compendium (CCC) expanded it further to FAST HUGS IN BED Please, with additional environmental control for delirium, a reminder to de-escalate therapies finishing it with psychosocial support (3).

FAST HUGS IN BED Please

  • Fluid therapy and feeding
  • Analgesia, antiemetics, and ADT (AAA)
  • Sedation and spontaneous breathing trial
  • Thromboprophylaxis
  • Head up position (30 degrees) if intubated
  • Ulcer prophylaxis
  • Glucose control
  • Skin/eye care and suctioning
  • Indwelling catheter
  • Nasogastric tube
  • Bowel cares
  • Environment (e.g., temperature control, appropriate surroundings in delirium)
  • De-escalation (e.g., end of life issues, treatments no longer needed)
  • Psychosocial support (for patient, family, and staff)

The above version was meant and applied in the emergency department or the intensive care unit as per Dr. Chris Nickson, last update July 23, 2019:3

Finally, this same concept can be easily applied in the emergency department as a modification FAST HUGS IN BED ED.

FAST HUGS IN BED ED will help both undergraduate medical students and residents in emergency medicine and critical care to revise and remember important areas of care. This has enormous benefits in a busy emergency resuscitation room as well as in complex ICU care settings.

References and Further Reading

  1. Vincent, Jean-Louis. “Give your patient a fast hug (at least) once a day.” Critical care medicine 33.6 (2005): 1225-1229.
  2. Vincent, William R., and Kevin W. Hatton. “Critically ill patients need “FAST HUGS BID”(an updated mnemonic).” Critical care medicine 37.7 (2009): 2326-2327.
  3. Dr. Chris Nickson, last update July 23, 2019, Life in the Fastlane – https://litfl.com/fast-hugs-in-bed-please/
Cite this article as: Temesgen Beyene, Ethiopia, "A mnemonic for the care of critical ED patients," in International Emergency Medicine Education Project, December 16, 2019, https://iem-student.org/2019/12/16/a-mnemonic-for-the-critical-ed-patients/, date accessed: June 7, 2023

The ABCDE Approach for Medical Students

The ABCDE Approach
~ Temesgen Beyene, Ethiopia ~ Leave a comment

Emergency Medicine Is a Dynamic Specialty

Emergency medicine is a dynamic specialty which mainly focuses on the rapid assessment and intervention of life-threatening conditions. It is well known that emergency patients are undifferentiated and mostly they come for unscheduled care. This is usually a new environment for a medical student in clinical years. Facing many undifferentiated patients and understanding the situation requires an initial standardized approach. There is an “ABCDE” approach which is universally accepted and applicable in all clinical emergencies for immediate assessment and intervention (1).

The Summary of ABCDE Approach for Medical Students

ABCDE assessment, which is also called primary survey is all about looking for immediately life-threatening conditions while at the same time doing lifesaving interventions. Rapid intervention usually includes O2 Support, IV access, the fluid challenge with or without specific treatment. The approach should take no longer than 5 min. It can be repeated as many times as necessary, depending on patient condition. During the ABCDE phase, you may recognize that the situation needs much more experience than critical but straightforward life-saving maneuvers. So, get experienced help as soon as you need it. Because resuscitation efforts need a team approach, If you have one, delegating jobs can help to move steps faster and smoother.

A - Airway

Acute Problems

  • Decreased GCS
  • Excessive secretions
  • Foreign body
  • Inflammation
  • Infection
  • Trauma, and so on.

Assessment

  • Unresponsive patient
  • Added sounds
    • Snoring, wheeze, stridor
  • Accessory muscles use
  • Irregular respiratory pattern

Interventions

  • Head tilt chin lift
  • Jaw thrust
  • Suction
  • Oral airway application
  • Nasal airway application
  • Advanced airway interventions (endotracheal intubation, surgical airway, etc.)

B - Breathing

Acute Problems

  • Decreased GCS
  • Respiratory depressions
  • Muscle weakness
  • Exhaustion
  • Asthma/COPD
  • Sepsis
  • Cardiac event
  • Pulmonary edema
  • Pulmonary embolus
  • ARDS
  • Pneumothorax
  • Haemothorax
  • Flail chest

Assessment

Look

  • Respiratory rate (Apnea/Bradypnea/Tachypnea), symmetry, effort, SpO2, color

Listen

  • Talking: sentences, phrases, words
  • Air entry, wheeze, silent chest other added sounds

Feel

  • Central trachea, percussion, expansion

Interventions

  • Consider ventilation with BVM (Bag-Valve-Mask Ventilation)
  • Consider ventilation with BVM
  • Position upright if struggling to breath (be careful in trauma patient)
  • Specific treatment like β agonist for wheeze, chest drain for pneumothorax

C - Circulation

Acute Problems

  • Loss of volume/Hypovolaemia
  • Pump failure (Myocardial & non-myocardial causes)
  • Vasodilatation (Sepsis, anaphylaxis, neurogenic)

Assessment

  • Look at color
  • Examine peripheries
  • Pulse, BP & CRT
  • Hypotension (late sign)
  • Decreased urine output

Interventions

  • Position supine with legs raised (shock position)
  • Left lateral tilt in pregnancy
  • IV access – 16G or larger x2 (+/- bloods if new cannula
  • Fluid challenge
  • ECG Monitoring
  • Specific treatment

D - Disability

Acute Problems

  • Inadequate perfusion of the brain
  • Sedative side effects of drugs
  • Toxins and poisons
  • Cerebrovascular accident (CVA)
  • Increased ICP

Assessment

  • AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) or GCS
  • Pupil size/response
  • Posture
  • Pain relief

Interventions

  • Optimize airway, breathing & circulation
  • Treat underlying cause (i.e., naloxone for opiate toxicity)
  • Control seizures
  • Seek expert help for CVA or high ICP

E - Exposure

  • Remove clothes and examine head to toe, including patients front and back. 
  • Look for hemorrhage, rashes, swelling, sores, syringe drivers, catheter, etc.
  • Keep the patient warm.
  • Maintain dignity

Reference

  1. Thim T, Krarup NH, Grove EL, Rohde CV, Løfgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med. 2012;5:117–121. doi:10.2147/IJGM.S28478

Further Reading

Cite this article as: Temesgen Beyene, Ethiopia, "The ABCDE Approach for Medical Students," in International Emergency Medicine Education Project, August 18, 2019, https://iem-student.org/2019/08/18/the-abcde-approach-for-a-medical-students/, date accessed: June 7, 2023

Undergraduate Emergency Medicine Clerkship: Ethiopian Experience

~ Temesgen Beyene, Ethiopia ~ Leave a comment

Emergency Medicine (EM) is about timely intervention and management of acute and life-threatening conditions (1). Every medical school graduate should learn and practice basic, yet important interventions for critically ill patients.

There are increased efforts in incorporating EM training into undergraduate curriculum worldwide (2, 3). However, the specialty of EM itself is yet not fully developed in low resource settings (4). South Africa is the first country starting to develop an EM system in Africa (5).

The modern medical education for both undergraduates and postgraduates level started in Ethiopia, at Addis Ababa University, in 1964. However, EM training as a specialty begun in the year 2010 (See infographic below). It was initially fragmented into different departments.

EM was also a 7-week separate elective rotation for undergraduates in the revised curriculum of 2008. It was successfully launched as training in 2013 with 300 4th year medical students (75 students in 4 groups). Students rotate in Adult EM (3 weeks), Pediatric EM (2 weeks) and Anesthesiology (2 weeks). Department of Emergency Medicine is the primary department controlling and managing these rotation areas in the clerkship. Our teaching program is primarily covered by EM, Pediatric EM, and Anesthesiology faculty. It includes practical demonstrations and simulation learning through our EM residents.

Topics covered by EM clerkship include:

Adult EM rotation

  • Introduction to EM
  • Basic Life Support (BLS)
  • Advanced Cardiac Support(ACLS)
  • Advanced Trauma Life Support(ATLS)
  • Approach to chest pain
  • Basic ECG and common arrhythmias
  • Approach to respiratory emergencies
  • Electrolyte emergencies
  • Approach to acute confusional state and neurological emergencies
  • Endocrine emergencies
  • Hypertensive emergencies
  • Approach to the poisoned patient and common toxicological emergencies

Anesthesiology rotation

  • Basic airway management devices 
  • Oxygen therapy
  • General and regional anesthesia with class discussions and practical demonstrations

Pediatric EM rotation

  • Pediatric assessment triangle
  • Pediatric advanced life support (PALS)
  • Newborn resuscitation
  • Common pediatric emergencies

Teaching methods are classroom didactics, case discussions, low fidelity simulations for basic airway management and ATLS demonstrations as well as case-based role plays for scenarios like Acute Myocardial Infarction, and so on.

Thus, in delivering such an innovative form of undergraduate rotation, our department has been selected as the best teaching department for the past 4 years consecutively by graduating medical students.

Cite this article as: Temesgen Beyene, Ethiopia, "Undergraduate Emergency Medicine Clerkship: Ethiopian Experience," in International Emergency Medicine Education Project, May 22, 2019, https://iem-student.org/2019/05/22/undergraduate-emergency-medicine-clerkship-ethiopian-experience/, date accessed: June 7, 2023